Report: Firefighter Scott Deem’s death was ‘preventable’

A state fire marshal's review of the blaze that killed San Antonio firefighter Scott Deem found several crucial mistakes while fighting the fire. Click through for a closer look at those critical errors.

A state fire marshal's review of the blaze that killed San Antonio firefighter Scott Deem found several crucial mistakes while fighting the fire. Click through for a closer look at those critical errors.

Photo: Jacob Beltran

Photo: Jacob Beltran

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Image 1 of 58 | Mistakes made in the fatal Ingram Square fire fight

A state fire marshal's review of the blaze that killed San Antonio firefighter Scott Deem found several crucial mistakes while fighting the fire. Click through for a closer look at those critical errors.

A state fire marshal's review of the blaze that killed San Antonio firefighter Scott Deem found several crucial mistakes while fighting the fire. Click through for a closer look at those critical errors.

Photo: Jacob Beltran

Report: Firefighter Scott Deem’s death was ‘preventable’

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The death of firefighter Scott Deem and the injuries to two other San Antonio firefighters at a Northwest Side strip mall last year “were preventable,” according to a report released Friday by the Texas State Fire Marshal’s Office.

“The actions leading to the findings in this report collectively led to the tragedy at this incident,” the report states. “The goal of this report is to challenge the San Antonio Fire Department to meet national fire service best practices identified in the recommendations to minimize risk exposure to the men and women of the SAFD.”

“That path will honor the memory of (firefighter) Deem and take a good fire department to an even higher level of performance,” it continues.

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San Antonio Fire Department Chief Charles Hood was grief-stricken as he explained why firefighters had to leave one of their own behind. Scott Deem was killed, and two firefighters were injured, while battling a blaze late Thurs., May 18, 2017.

Media: San Antonio Express-News

In total, the report identifies 11 mistakes that were made as firefighters battled the massive blaze at the Ingram Square Shopping Center on May 18. (On Thursday, the Express-News reported there were 10 findings, based on information from San Antonio Fire Chief Charles Hood.)

The mistakes range in severity, from more critical issues dealing with firefighting operations and the accountability of commanders, to less severe infractions, like how training is documented.

Overall, though, the review portrays the department as one lacking accountability and in need of a “cultural change.” At the end of the report, the fire marshal’s office includes a 27-page U.S. Fire Administration report on how to reduce “risk-taking behaviors in the fire and emergency service.”

“While San Antonio Fire Department has many good policies and procedures in place, pockets of members remain who are resistant to change,” the report states. “The SAFD would benefit from a culture of continuous improvement.”

The 61-page independent review, which was conducted with assistance from the Houston Fire Department, provides the most comprehensive explanation of what happened the night in May when Deem died.

Until Thursday, Hood had said little specifically about the firefighting operations, citing the ongoing local, state and federal investigations. When he did speak about it, he staunchly defended the department’s actions.

Now, though, Hood has backed off of those claims, saying mistakes were made.

“There’s a void there that’s never going to be replaced,” Hood said. “We have to make sure we do justice to his loss.”

Lessons learned

According to the report, Deem — a 31-year-old father who had been with the department for six years — arrived at the fire at 9:17 p.m. May 18 and almost immediately forced his way into the building to search for people possibly trapped inside.

Firefighter Brad Phipps, a comrade from Station 35, entered the building with him.

The report states that commanders never should have sent firefighters into the building initially. The gym was closed, there was “heavy dark black smoke” coming out of the building and there was no evidence anyone was inside the building — something that proved true as the fire progressed.

The firefighters entered the structure without a hose, leaving them without a water supply or a clear way to exit the building once visibility diminished. Those tactics are similar to those used in a small residential structure — not a large commercial building, the report found.

More Information

Fire marshal’s recommendations:

Use firefighting techniques appropriate for the type of structure and conditions of the fire

Ensure proper ventilation and fan usage

Properly educate incident commanders on risk management, and when to go/no go

Prevent freelancing, when an individual carries out tasks without approval from the incident commander

Implement an “accountability system” and procedures that track crews and breathing apparatuses

Evaluate and train on mayday procedures

Ensure pre-fire plans, such as floor plans, are in place

Conduct fire code inspections of all commercial buildings

Provide easy access to current standard operating procedures and guidelines

Adopt “cultural change” with a greater emphasis on firefighter accountability and safety

Document all firefighter training in a central location

As the two searched the building, Phipps said the visibility was poor and they were moving by touch alone. He then told commanders they had located the fire in the attic.

Phipps, and possibly Deem, began pulling ceiling tiles to gain access to the fire, but conditions quickly changed, the report states. They reported they had no visibility and heat was rapidly increasing.

“It was like someone poured asphalt over me,” one firefighter later told investigators. “It got very dark and very hot.”

Pulling ceiling tiles, the report states, is typically done to find the origin of the fire, not during a search-and-rescue operation. The report criticized this form of “freelancing,” when an individual carries out tasks without approval from the incident commander.

And, if they were to pull tiles, they needed a hose-line in place — which they did not.

Nearby firefighters attempted to cool down the area by opening a fire nozzle, but it had little effect and they backed out of the building, the report says.

Soon after, Phipps issued a “mayday,” meaning he was in immediate danger. The pair attempted to exit the structure but were overcome by the fire and became separated.

Throughout the fire, crews failed to properly ventilate the building, the report states. At one point, according to radio traffic, commanders thought the gym’s back doors had been opened and that the building was being adequately ventilated to clear out the thick smoke.

In fact, though, at least some of the doors were still shut and the smoke wasn’t clearing.

Meanwhile, Robert Vasquez, a third firefighter who had entered the gym as part of a Rapid Intervention Team to search for Deem and Phipps, was separated from his team. The air in his breathing apparatus was low, so he changed his bottle and stayed in place, thinking he wasn’t in trouble.

On Thursday, Hood said Vasquez’s decision to change his breathing apparatus and stay in place was heroic — it kept crews focused on the mission to find Deem and Phipps — but he also said Vasquez should have issued a mayday before it was potentially too late.

Firefighters are often wary of calling mayday, but it can save lives, Hood said.

Rescue teams eventually found Phipps and pulled him out of the building. Phipps was hospitalized for months after the fire and continues to recover from disfiguring injuries.

A half-hour into the incident, they found a second firefighter, who they thought was Deem. Then came bad news. The firefighters had not pulled out Deem, but Vasquez.

Commanders need an “accountability system” and procedures that track crews and breathing apparatuses to make sure something like this never happens again, the report states.

Faced with a growing inferno and a burning roof that could collapse at any time, Hood said he ultimately ordered all the rescue teams to evacuate the building, leaving Deem inside.

Crews found Deem’s body later as the smoke began to clear. His body was removed from the structure, surrounded by his fellow firefighters and draped with an American flag from Station No. 35 on Culebra Road, where he worked.

Finding forgiveness

The report details other errors made by the department — like not having updated floor plans on file and failing to provide easy access to current standard operating procedures. Hood said it’s important for those errors to be corrected but said they did not affect the chain of events that night.

Hood said the department needs to focus on learning from the mistakes and forgiving itself, saying the real blame for the fire falls on the person who intentionally set the fire inside the Spartan Box gym in the shopping center, allegedly to get out of his lease.

“It’s up to all of us to be accountable for our actions,” Hood said. “But like I told you, we have to forgive ourselves. We have to forgive ourselves and without that, we’re never going to recover and we have to do that.”

Some city officials — including City Manager Sheryl Sculley and City Council members Manny Pelaez, William “Cruz” Shaw and Rey Saldana — echoed those sentiments and said they supported Hood.

“It opens a wound for the city and for the department and families from a very terrible night in May,” Mayor Ron Nirenberg said in a statement. “But in looking at the report and hearing from the Fire Department leadership, the institution didn’t fail. Of course, in any incident like that, there are things that we could do better.”

“My personal experience with Chief Charles Hood as a citizen, as a Councilman and now as Mayor, has been exemplary,” he added. “I have been impressed with his response to this terrible event and have confidence that he will continue to lead the department forward.”

After the fire, Hood said the department identified policies and training practices that needed to change — some of which were also cited in the state fire marshal’s report. The department’s updates began in June.

The department said it will implement the additional recommendations from the state fire marshal’s office in the months and years to come. The department has reassigned a command staff leader to directly oversee the implementation of the report’s recommendations.

The department also has also turned an old warehouse on North Cherry and Nolan streets on the East Side into a safety and survivability center dedicated to Deem. The structure will have props, and firefighters will go through training exercises to escape from fake entrapments, entanglements and zero-visibility conditions.

“We have an obligation to make sure that this doesn’t happen again,” Hood said. “And so that is what we’re trying to do.”